Significant Case Review published following death of Sharon Greenop

 24 April 2019  |  

South Ayrshire Adult Protection Committee

South Ayrshire Adult Protection Committee

The South Ayrshire Chief Officers' Group (COG) for Public Protection has today (24 April) published the findings of an independent Significant Case Review into the circumstances surrounding the death of 46-year-old Sharon Greenop, who was found dead at her home in Troon in November 2016.

Sharon's sister, Lynette Greenop, was convicted of her murder and sentenced to life imprisonment for her crime in May 2018.

Prior to her death, Sharon received a community care package from social work services within the South Ayrshire Health and Social Care Partnership.

The purpose of the Significant Case Review was to consider social work's involvement with Sharon and identify whether there were lessons to be learned about how better to protect adults at risk.

The review was led by independent review chair and extremely experienced senior social worker, David Crawford, with the review team comprising representatives from South Ayrshire Council, NHS Ayrshire & Arran and Police Scotland.

The review found that responsibility for Sharon's death lies with the person convicted of her murder – her sister, Lynette – and that no one could have foreseen her violent death.

However, it also identified a number of issues for the South Ayrshire Health and Social Care Partnership:

  • The decision to allow Sharon's care package to be closed was flawed and allowed the circumstances to develop that ultimately led to her death.
  • The Partnership missed opportunities to raise adult protection concerns regarding Sharon's wellbeing, which could have resulted in interventions that could have stopped Sharon being abused.
  • Sharon's community care package was one of hundreds that hadn't been reviewed by the Partnership in a number of years despite a statutory obligation and a corporate policy to undertake annual reviews.
  • The duty system – the initial response for social work referrals – was not fit for purpose and previously identified failings had not been sufficiently addressed.
  • Record-keeping was extremely poor and hampered by outdated information systems, meaning there was insufficient information about Sharon's care and wellbeing and it was difficult to manage her case effectively.
  • Management practice was poor in places and didn't support efficient and effective working practices.

The report concludes that there are undoubtedly lessons to be learned from Sharon's death and the report sets out five clear recommendations for the Partnership:

  • Ensure proper steps are taken before the closure of a care package and before the transfer of cases between teams.
  • Ensure comprehensive arrangements are in place to review care packages on at least an annual basis and report to the Adult Protection Committee on compliance.
  • Ensure the roll-out of the Carefirst system across all services within the shortest achievable timescale.
  • Continue to rigorously monitor the effectiveness of the duty system in adult services and report to the Adult Protection Committee on progress.
  • Make an immediate decision in relation to the outstanding disciplinary issues resulting from this case.

Professor Paul Martin CBE, independent Chair of the South Ayrshire Adult Protection Committee, said: "Sharon's violent death was a tragedy that no one could have foreseen and our thoughts are with her family and friends. It's clear that steps could have – and should have – been taken by the South Ayrshire Health and Social Care Partnership that could have stopped the abuse she suffered before her untimely death.

"That's unacceptable and through the Adult Protection Committee and the Chief Officers' Group – which I report to and includes the chief officers from the Council, police and NHS – I'll be ensuring that the necessary improvements are put in place as quickly as possible and visibly make a difference for people and communities in South Ayrshire.

"The Committee will monitor progress closely and seek clear evidence from the Partnership to ensure we know – for a fact – that services are improving and continue to protect vulnerable people from harm.

"This will mean we can all be reassured and can have confidence in the social work services delivered to vulnerable people across South Ayrshire on a daily basis. That's what matters and I will ensure the Adult Protection Committee plays its part to hold these services to account and ensure they work in the right way to safeguard adults at risk.

"Sadly, these changes can't bring Sharon back, but they can ensure the Partnership does all it can prevent similar circumstances developing where someone like Lynette Greenop can commit such a vile and evil crime.

"This review has been very difficult for everyone involved, but especially Sharon's family, and I hope the outcomes provide some closure for them as they continue to come to terms with their loss."

Tim Eltringham, Director of the South Ayrshire Health and Social Care Partnership, said: "We take our responsibilities to protect vulnerable adults from harm very seriously. And while we know it won't bring Sharon back, we are deeply sorry that we failed Sharon and her family and I have delivered that apology in person to her sister, Diane Hogg.

"We fully accept the findings of the review and recognise where we fell down in delivering the standard and quality of service that Sharon needed and deserved. We're doing everything in our power to ensure this cannot happen again and we've made a lot of progress in improving how we work.

"This has focused on strengthening our adult protection procedures and making the best possible use of the resources available to support vulnerable people in our communities.

"We've made significant changes to the duty system – our initial response system for social work referrals – and how we manage community care cases. We're also rolling-out the Carefirst social work management information system and improving our management structures to ensure better oversight and governance.

"Progress in relation to all of these improvements will continue to be audited and monitored on an ongoing basis through both our senior management team and the Adult Protection Committee.

"Our social work staff work incredibly hard and make difficult decisions every day to support vulnerable people in our communities and keep them safe and well. I'm confident the changes we have made will deliver the necessary improvements to support them to better help protect people and keep them safe from harm."

The Significant Case Review into the circumstances surrounding the death of 46-year-old Sharon Greenop can be found at